Traumatic Eye Injuries Sarasota Memorial Hospital September, 2009 Kelly P. O’Keefe, MD, FACEP Program Director USF Emergency Medicine Residency Traumatic Eye Injuries Today we will review… 1. 2. 3. 4. Variety of ocular injuries Basic anatomy Visual recognition of injuries Sight-saving procedures Traumatic Eye Injuries Why pay attention today? A. We see a lot of eye injuries B. The number of really serious injuries is increasing C. We need to be on top of our game to diagnose and treat the worst ones properly D. All of the above Epidemiology • • • • • 2.4 million eye injuries in the US annually 15% occur in the workplace 80% males Young population 50,000 new cases of trauma related monocular blindness each year Where do most eye injuries occur? A. B. C. D. E. Home Work Sports Highway Other Make your selection please… Epidemiology Home Work Highway Sports Other/Unknown 40% 15% 15% 15% 15% Epidemiology Sports Baseball / Softball Fishing Basketball Golf Racquetball Tennis Soccer Football Witherspoon et al, Opth Clin N Am Vol 12 1999 33% 28% 10% 8% 6% 5% 5% 4% Anatomy • Relatively thick bones superiorly and laterally • Thin medial wall and orbital floor • Closed space • Proximity to brain and sinuses SR elevates, adducts, rot. medially SO depresses, abducts, rot. Medially MR adduction Obliques protrude the eye IR depresses, adducts, rotates lat IO elevates, abducts, rot. Laterally LR abduction recti retract it How Thick is the Cornea? A. B. C. D. E. 0.5 mm 1 mm 2 mm 2.5 mm 3 mm Make your selection, please. Priorities • • • • • Stabilize the patient Assess visual pathways Assess global integrity Provide sight saving procedures Consult early Sight-saving Procedures • Irrigation • Globe protection • Lateral canthotomy History • Proceed after assessment of ABC’s and addressing life threats • Obtain detailed history of what happened to the eye • Obtain past ocular history, including contact wear, and medical problems affecting the eye • Describe visual symptoms External Eye Exam • Look for – – – – – – Trauma Infection Dysfunction Deformity Proptosis Subcutaneous emphysema • Palpate the orbital rim Visual Acuity • • • • • Distance chart, handheld chart Count fingers Hand motion Light perception Use glasses or pinhole to document best acuity as possible • Use topical anesthetic if required Visual Fields • Test gross confrontational fields Pupillary Exam • Look for relative afferent pupillary defect to identify an optic nerve injury • Assess size and roundness, regularity • Anisocoria may be caused by trauma, cycloplegics, PCA aneurysm, prior trauma or surgery RAPD Ocular Motility • Test all six EOM’s, CN 3,4,6 – SO4 – LR6 – R3 • Motility is impaired by constriction, nerve injury, trauma • Diplopia present Anterior Segment • Best done with slit lamp • Examine all portions of anterior chamber for injury • Evert lids • Use fluorescein dye Fundus • Dilate pupils for best results • Document full pupillary exam first • Look for foreign body, blood, detachment, other Before dilating… IOP • Don’t measure if globe rupture suspected • Increased with hyphema Injuries Is this just a Subconjunctival Hemorrhage.? No… Corneal Abrasion • Pain, photophobia, • • • • tearing Topical anesthetic relieves pain Identify source when possible Evert lids Use slit lamp Corneal Abrasion Corneal Abrasion • Evaluate for foreign • • • • • body Dilate (homatropine) Antibiotic ointment Tetanus Follow up Contacts? Which mechanism is most worrisome for an IOFB? A. Working under a car removing a rusted B. C. D. E. muffler Welding Sanding wood with an orbital sander Striking a nail with a hammer Forgetting your anniversary Make your selection, please. Corneal Foreign Bodies • If metal on metal, rule out intraocular foreign body • Don’t assume there is only one… • Remove foreign body and rust ring • Refer Foreign Bodies Corneal Foreign Bodies • Topical Anesthetic in ED • Pain meds at home • Topical antibiotics • Cycloplegia Clues to Perforation • Hemorrhagic • • • • • • chemosis Shallow anterior chamber Hyphema Irregular pupil Significant reduction in visual acuity Poor view of fundus Positive Seidel’s Scleral Laceration Scleral Laceration Lacerations: Yes or No? Should you try to repair this laceration in your office? A. Yes B. No C. Maybe Yes or No? • Refer for wound closure, unless you have no choice • Canalicular system injuries must be referred Blunt Trauma • Visualization of eye may be difficult. Use speculum • Assess visual acuity and globe integrity • If the anterior chamber is flat, make no further attempt to assess the eye. • Sight Saving Procedure: Sight Saving Procedure • Place a metal protective shield over the eye and don’t let anyone touch it! • Use a styrofoam cup if you can’t find a shield Speculums Globe rupture • Administer antibiotics • NPO • Consult Globe Rupture Blunt Trauma • If globe appears intact, • • • • proceed with exam Look for hyphema grossly Assess EOM for entrapment Palpate orbital rims Assess for sensory loss Blunt Trauma • Perform a slit lamp • • • • exam Use fluorescein Look for evidence of pupillary irregularity Dilate and do a fundoscopic exam Refer even if no injuries found Mechanism for Blunt Injury • Eye is struck • Cornea pushed inward, compressing globe • Rupture may occur at weakest points (recti insertion, cornealscleral limbus) • Pupillary sphincter may rupture Mechanism for Blunt Trauma • Iris may be avulsed from • • • • ciliary body Anterior chamber recessed, tears ciliary body, hyphema forms Blood cells clog meshwork, >IOP Zonular ring may be torn, dislocating lens Bleeds and detachment posteriorly Mechanism for Blunt Trauma Mechanism for Blunt Trauma Suspect traumatic optic neuropathy when other cause of acute significant visual loss cannot be found Check for RAPD Orbital Compartment Syndrome • • • • • • History of trauma Pain, Proptosis Resistance to retropulsion of the globe Markedly decreased or absent vision/RAPD Consult immediately for treatment options Medical management? Topical beta blocker, diamox, mannitol Sight Saving Procedure: Canthotomy and Cantholysis • Must be done aggressively • Local anesthesia • Grasp lateral canthus with • • • • hemostat, crushing tissue Incise with scissors Grasp lower lid with forceps and pull outward until you can feel the attachments to the lid on the orbital rim. Cut the insertions, and the lateral canthal tendon. Repeat on upper lid if needed Eye will push forward, relieving pressure www.brown.edu/ Administration/Emergency_Medicine/eye.htm • Appearance post canthotomy: • Needle decompression if this fails • Localize blood first Carotid Cavernous Fistula • 2-3 days post trauma • Diplopia, noises in head, engorged vessels, elevated IOP, pulsatile tinnitus • Visual loss • Management by Neurosurgery and interventional neuroradiology • Findings more subtle if dural based Grading Hyphemas O: no layered blood 1: less than 1/3 2: 1/3 to ½ 3: >1/2 4: Total (8 ball) Treatment of Hyphemas • Assess for rupture / penetrated globe • Elevate head to allow cells to settle • Dilate the pupil (normal iris constriction and dilation will stretch vessels, causing rebleed) • Treat elevated IOP • Amicar (antifibrinolytic) per ophtho • Generally admitted Blow Out Fractures Blowout Fracture • Paralysis of Upward Gaze • Diplopia on upward gaze • Enophthalmos (rare) • Infraorbital anesthesia What injury is present here? Make your selection, please: A. B. C. D. E. Retro-orbital bleed, right eye Medial rectus entrapment, left eye Superior orbital fracture, right eye Prosthetic eye, left side No injury, he has multiple sclerosis Blowout Fracture • 33% involve eye: consult ophtho even if • • • • asymptomatic If no entrapment, eye injury, conservative treatment Oral antibiotics Specialty follow up Avoid blowing nose Traumatic Iritis • Occurs 2-3 days after • • • • the event Pain, photophobia, redness, blurring Not relieved by topical anesthetic Cells and flare Consensual pain Traumatic Iritis • • • • Rule out other injury Cycloplegia Consult ophtho Topical steroids Commotio Retinae • • • • • Follows blunt trauma Uncommon Retinal whitening, edema Contracoup type injury Occurs within hours, resolves within days • Visual acuity decreased,(esp. at macular involvement) scotoma • Refer to retina specialist • Visual loss may persist Airbag Injuries • Velocity of inflation 200 mph • Classic sequelae of blunt trauma for eye • Safety glasses for driving? Airbag Injuries Penetrating Injury • More likely to have long term impairment • Globe rupture-Prognosis better with: – Visual acuity 20/200 or better – Penetrating injury – Injury anterior to rectus muscle – Injury length less than 1 cm Sight Saving Procedure • A true emergency! • First priority copious irrigation • Wait on visual acuities • Assess pH intermittently • Ensure lids and corners irrigated Grading Chemical Injuries I: loss of corneal epithelium II: stromal haze and small amount limbic ischemia III: widespread stromal haze and obscuration of iris, larger ischemia IV: opaque cornea, >50% limbic ischemia “Good” prognosis for I and II Which exposure has a better prognosis? A. Acid burn to the eye B. Alkali burn to the eye Chemical Injuries • Acid coagulates protein, limiting depth of injury • Alkali may have severe penetration, causing damage to deep structures within minutes • Both can be blinding Chemical Injuries Superglue • Remove clumps from eyelids • Erythromycin ointment to moisten, lubricate, and dissolve • Refer to ophtho • Usually not permanently harmful Thermal Injuries • History of exposure • Pain, tearing, decreased vision, redness, FB sensation • Differentiate from welder’s flash • Corneal epithelial defect • Corneal whitening = stromal burn Thermal Injuries • Rule out ruptured • • • • • • globe Consider chemicals Topical antibiotics Cycloplegia Pain meds Patch Ophtho Remember… • Protect a ruptured globe • Irrigate copiously • Canthotomy and cantholysis as an emergency sight saving procedure • Keep your eyes out for potential injuries… …but not to this extent.